LYON COUNTY 4-H MEMBER ENROLLMENT FORM
4-H Year:
Please read and complete ALL information on both sides of Member Enrollment and Commitment to Excellence. Deliver to a 4-H Program Manger or mail to UNCE-Lyon County, 504 S. Main St., Yerington, NV 89447.
The annual Enrollment Fee is $5.00, payable to “Lyon County 4-H Leaders’ Council”
Some Clubs and/or Projects may have nominal fee/s.
NAME:
Last First Middle Initial
MAILING ADDRESS:
Number Street (Apt./Suite#)
CITY: STATE: ZIP: HOME PHONE:
CELL PHONE:______EMAIL ADDRESS:
BIRTH DATE: _____/_____/_____ 4-H AGE: ______(Age on January 1st) GENDER: M F
MILITARY AFFILIATION (Parent/Guardian on active duty, National Guard, Reserve, civilian attachment) ______yes ______no
Parent/Guardian Branch of Military Service: ______
RACE (Optional; Check All That Apply) ETHNIC Origin (Optional) RESIDENCE: (Check one)
White (Caucasian) ______Hispanic Farm/Ranch _____
Black (African Amer.) ______Not Hispanic Town under 10,000 & rural non-farm _____
Native American ______City 10,000 -50,000 _____
Hispanic (Latino) ______Suburb of city over 50,000 _____
Asian/Pacific Islander ______City over 50,000 _____
SCHOOL ATTENDING & GRADE: EMERGENCY PHONE NUMBERS FOR PARENT/GUARDIAN:
/
(Please indicate if home schooled) (Grade) (Please indicate name and numbers)
YEAR(S) IN 4-H (include this year) CLOVERBUD: ______(5 – 8 years of age as of Jan. 1st)
SPECIAL INFORMATION you would like to make us aware of (medical/physical limitations, etc.):
______
4-H CLUB / PROJECT INFORMATION
4-H Member please print legibly; see next page for more options
I have read and agree to all information and statements as noted on both sides of this Form. Signatures required.
I hereby give permission for my child to become a 4-H Member:
PRINT Parent or guardian name Signature Date
PRINT Member name Signature Date
The University of Nevada, Reno is committed to Equal Employment Opportunity/Affirmative Action in recruitment of its students and employees and does not discriminate on the basis of race, color, religion, sex, age, creed, national origin, veteran status, physical or mental disability, and sexual orientation. The University of Nevada, Reno employs only United States citizens and aliens lawfully authorized to work in the United States. Women and under-represented groups are encouraged to apply.
ASSUMPTION OF RISK
For myself, and my heirs, executors, administrators, legal representatives, assignees and successor in interest (collectively referred to as “successors”), I release, forever discharge and agree not to sue the Nevada System of Higher Education, its employees, agents, members, sponsors, volunteers, officials, spectators, or owners of property on which 4-H activities may be conducted from any and all liability, claims, loss, cost or expense, including, but not limited to, those arising from property damage or loss, injury to my body, mental trauma or death, and waive any such claims against any such persons or organizations, arising directly or indirectly from, or attributable in any legal way, to any negligence or other action or omission to act of any such persons or organizations in connection with the sponsorship, or organization or conduct of the Nevada 4-H program including travel to and from events or activities in which I may be a participant, spectator or volunteer. I hereby waive all such claims, which I have now or may hereafter have against the above organizations or persons, however caused.
CODE OF CONDUCT FOR 4-H MEMBERS
As a member of the University of Nevada Cooperative Extension 4-H program, I agree to conduct myself in a respectful manner, exhibit good sporting conduct and be a positive role model. I will be courteous and display appropriate behavior to all individuals affiliated with the Nevada 4-H program per the UNCE-Lyon County Commitment to Excellence.
CODE OF CONDUCT FOR PARENT/GUARDIAN OF A 4-H MEMBER
As a parent/guardian of a 4-H Member in the UNCE 4-H program, I agree to conduct myself in a respectful manner, exhibit good sporting conduct and be a positive role model. I have read and agree to model/follow appropriate behavior as addressed in the Nevada 4-H program per the UNCE Volunteer Code of Conduct adopted by the Extension Governing Board 5/18/00.
PHOTO/AUDIO/VIDEO/QUOTE/NAME/TOWN RELEASE YES NO
I grant the right to use the materials/information listed above for educational and promotional use, as directed by the university, without payment or remuneration for any appearances, use or displays. I acknowledge the university’s right to crop or treat the display of my photograph at its discretion. I understand that the university may use these materials in printed and Internet publications and presentations that they produce, and that they may also give the materials/information to media and other organizations for educational or promotional use. I also understand use of these materials/information is done without remuneration/payment to me.
PROJECTS AND CLUBS ARE ONLY AVAILABLE IF OFFICIAL
UNR VOLUNTEERs/UNCE LEADERs VOLUNTEER TO LEAD THEM.
INTERESTED IN BECOMING A LEADER? CONTACT THE UNCE-LYON COUNTY OFFICE.
I am interested in the following 4-H projects:
LIVESTOCK _____HORSEMANSHIP
_____BEEF _____COMMUNITY CLUB
_____SHEEP _____TOLE’ PAINTING
_____SWINE 4-H CAMP
GOAT _____LEGO CONSTRUCTION
_____LEGO ROBOTICS
_____LIVESTOCK SKILLATHON _____FIRST AID/CPR
_____SKI/SNOWBOARDING _____SPEED STACKING
_____RABBITS / CAVIES _____FLORICULTURE
_____CLOVERBUDS (4-H AGE 5-8) _____ARTS & CRAFTS _____TRIBAL 4-H _____COOKING / FOODS _____GARDENING
_____SEWING / CLOTHING _____SHOOTING SPORTS (Rifle [Air, .22], Shotgun; Archery)
_____PHOTOGRAPHY
_____DRAMA _____4-H AFTERSCHOOL PROGRAM
_____DOG CARE & TRAINING _____TEEN COUNCIL / LEADERSHIP PROGRAMS
_____JUNIOR LEADER (13-15) INDICATE PROJECTs/CLUBs ______
_____TEEN LEADER (16-19) INDICATE PROJECTs/CLUBs ______
_____ 4-H MENTORING PROGRAM Indicate if you are a Mentor or Mentee ______
IF YOU ARE INTERESTED IN ENROLLING IN PROJECT/S NOT LISTED ABOVE, PLEASE INDICATE THE SUBJECT
AREA: ______
INTERMEDIATE AND SENIOR MEMBERS MAY ENROLL IN “SELF-DETERMINED” OR SELF GUIDED PROJECTS WITH PERMISSION OF UNCE-LYON COUNTY 4-H. CONTACT UNCE-LYON COUNTY OFFICE FOR MORE INFORMATION.
9/4/2012
University of Nevada Cooperative Extension
Lyon County 4-H – Commitment to Excellence
I believe participation in the UNCE-Lyon County 4-H Program, and its Livestock Projects and/or Clubs, should demonstrate my own knowledge, ability and skill in my Project.
I will do my own work to the best I am capable and accept only advice and support.
I will not use abusive, fraudulent, illegal, unethical or questionable practices in my 4-H Projects including the feeding, fitting, showing or selling of my livestock. I will not allow my parents, my Leaders or any other individual or group to employ such practices with my Projects.
I will conduct myself in a respectful manner, exhibit good sporting conduct and be a positive role model.
I will display respect and courtesy for UNCE employees, adult volunteers/Leaders, judges, program participants, visitors, clients and property.
I will not use or have in my possession alcohol, tobacco or illegal drugs while attending any 4-H event or activity.
I will read, understand and follow the General Rules and Regulations For The Lyon County Junior Livestock Show, Nevada Junior Livestock Show Rules, Nevada State Fair Competition Guide and similar documents for any livestock exhibition in which I am a participant, asking my Leader(s), parents and those involved in my Project to do the same.
I wish for participation in this livestock Project/Club to teach me how to accept what life has to offer, both good and bad and how to learn from the outcome.
I consent to having my livestock Project tested for illegal substances, for substances exceeding established tolerances or substances not approved for use in livestock destined for human consumption (as determined by USDA and/or NDOA guidelines.)
I realize I am responsible for:
· the proper care and safe, humane treatment of my livestock,
· the production of a high quality, safe and wholesome food for consumers (Market Projects), and
· demonstrating strong moral character at all times being a positive example to others.
I have read and understand this Commitment and will follow the above guidelines to ensure I commit to excellence in this youth development endeavor. I understand if at any time, I do not follow these guidelines, my 4-H Project/Club Leader or Program Manager can dismiss me from the UNCE-Lyon County 4-H Program and some or all of its activities.
______
Youth/Member Date
______
Parent or Guardian Date
Completed signatures certify the Youth/Member is eligible to participate fully in the UNCE-Lyon County 4-H Program.
9/4/2012